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0 0 <br /> -The Tree Adobe Reader may be used to view and complete this form. However,software must be purchased to xnmplete,save,and reuse a saved form. <br /> File Original with DWR State of California DWRUse On —DO Nat FYI In <br /> Well Completion Report <br /> Page of aererm Inrn csnn Pamphlet Stale Well NumhedSke umber <br /> •Owner's Well Number W^ No. 0095023 �_.L� ���1--�-1W <br /> Date Work Began ^10 ro Date Work Ended 7 'l+ "� tan �° <br /> Loral Permit Agency �s a/+ a.^ noir' _ APNrlFtSlOther <br /> Permit Number L PStmh Date <br /> Geologic Log Well Owner <br /> Orientation P'Verfical 0Horizontal OAngle Specify [Na:m 1- O <br /> Dolling Method /' 4r Drilling Fluid g Address �"� r �� r; <br /> Depth from Surface Description Stalef4/7i <br /> Feet m Feet Describe material, rain size,colo,etc <br /> Well Location <br /> r,S Fi. ddress <br /> City a^ -County-'-s-^-��e "` ... <br /> c- Latitude N'Longhude__-__W <br /> Doo. Mina Seca 5e0Min, Sec <br /> Datum Dedmal Lat. Decimal Long. <br /> APN Book Page Parcel <br /> t <br /> Township Ra Section <br /> f.. �� �. nn . 'GDcation Sketch. —Activity <br /> ketdimustee dravmb AftirMmis need. O New Well <br /> ` O Modification/Repair <br /> O Deepen <br /> O Other <br /> 3KDestmy <br /> \ <br /> 'GEOLOG4CGC LW newMp^ mMMaY <br /> +r. ... .\ weeW' <br /> Planned Uses <br /> OWater Supply <br /> ` \ ❑Domestic ❑Public <br /> ❑Irrigation ❑Industrial. <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heat Exchange <br /> ---...... �^ 0Injection <br /> ♦Monitoring <br /> gg O Remediation <br /> Jl ttz , A O Sparging' <br /> Uest Wel <br /> O Vapor Extraction _. <br /> m.n,a e,a erod,>man uw.faie,.l pie r,eure,r. O Other <br /> rr..a.r<er.rrawm <br /> Water Level and Yield`of Com leted Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date uned <br /> Total Depth of Boring et Estimated YieldG est Type <br /> Total Depth of Completed Well - Feel Test Length (Hours)Total Drawdown_(Feet) <br /> *May not reseniative of a well's long term 'eld. <br /> Casings Annular Material <br /> Depth from Borehole Type Material Wall Outside Screen a=Size Depth from <br /> Surface Diameter Thickness Dlamslar Type It Any Surface. Fill Description <br /> Feet to Feet Inches Inches Inches Inches Feel ro'feet <br /> Attachments Certification Statement <br /> ❑Geologic Log I,the undersigned,certify thaM rPp co a accurate to thekesi of knowledge and bel'lef <br /> ❑Well ConsWction Diagram Name L='V u f <br /> ❑Geophysical Log(s) CA ✓I <br /> ❑SoillWaler Chem' Analyses ° <br /> ❑ Other Signed F+r' <br /> Adorn Addlioneli on rases.. . c-n w.mrwr ednvadar toSig Iled C-57 License Number <br /> DNT2INI REV IFAObmONAL SPACE IS NEEDED.USE NEXTCONSECUTWELY NUMBERED FORM <br />